WELCOME TO GLOUCESTER COUNTY PUBLIC SCHOOLS. Student Registration Form School s Name: Peasley Middle School

Transcription

1 WELCOME TO GLOUCESTER COUNTY PUBLIC SCHOOLS Student Registration Form School s Name: Peasley Middle School (Please print these forms, fill them out and bring them to Peasley with all the required documents) FOR OFFICE USE ONLY Student ID# Entry Date: YOG: Entry Code: PK Code PK Time Homeroom #: Counselor/Teacher Team: Bus #: Are you a resident of Gloucester County? Yes No Items accepted as proof of residency: lease/deed and current utility bill Has your student ever attended a Gloucester County Public School? Yes No If yes, which school did your child attend? Abingdon Achilles Bethel Botetourt Petsworth T. C. Walker Page Middle Peasley Middle Student s Legal Name: LAST FIRST MIDDLE NICKNAME Gender: Male Female Student s Ethnicity: SEE ATTACHED FORM Student s Birth Date: / / Place of Birth: Birth Certificate # Student s Grade Level: Primary language spoken by student: English Spanish French Russian Chinese Vietnamese Other Primary language spoken at home: English Spanish French Russian Chinese Vietnamese Other Student s Mailing Address: Student s Home Phone Number: Student s 911 Address-required: (If different than mailing) Number Street Name City Zip Code Does your child currently receive special services? YES NO If yes, please check all that apply: Speech Special Education 504 Gifted ESL Occupational Therapy/Physical Therapy Other Student Resides With: Mother & Father Mother only Father only Grandparents Foster Parent(s) Mother and Stepfather Father and Stepmother Guardian/Custodian Other Name: Address (if different from student): Place of Employment: Work Phone #: Cell Phone #: address: Name:

2 Address (if different from student): Place of Employment: Work Phone #: Cell Phone #: address: If the student is NOT residing with BOTH biological/adoptive parents, please list other parent s information (i.e., name, address, etc.) EMERGENCY CONTACT INFORMATON (Our schools attempt to contact the parent/guardian first the following information is for OTHER than parent/guardian) Contact Person 1: Phone #: Relationship to Student: Contact Person 2: Phone #: Relationship to Student:

3 GLOUCESTER COUNTY PUBLIC SCHOOLS Peasley Middle School 2885 Hickory Fork Road (804) (804) Last School Attended: Name Mailing address: Phone #: Fax#: Name of Student Date of Birth Grade By signing below I authorize the release of all scholastic records to include the following: Health, including immunization record Discipline Special Education 504 Gifted Virginia SOL scores Virginia State Testing ID Number any other pertinent records to Gloucester County Public Schools. I have willfully and knowingly provided the correct information. I will provide Gloucester County Public Schools any new information concerning my child as it occurs. Before enrolling your child in Gloucester County Public Schools, you must provide the following: Proof of Residency (lease/deed and current utility bill) Certified Copy of Birth Certificate Updated Immunization Record Physical Exam Report Transcript From Former School -can be unofficial(high SCHOOL ONLY) IEP and/or 504 (if applicable) Legal Papers Referencing Student (if applicable) Parent/Legal Guardian Signature Date No student can be prevented from participation in any program solely because of his/her race, color, national origin, sex, age, religion or disability. A procedure for resolving complaints alleging discrimination on the basis of race, color, national origin, gender, age, religion, or disability may be found in the manual for Policies and Regulations of the Gloucester County Public Schools. The Section 504 and Title IX Coordinator for the Gloucester County Public Schools is : Ms. Rita Cargill-Brown, Section 504 and Title IX Coordinator Gloucester County Public Schools 6489 Main Street - Building Two, Suite F (804) Student Services Form - Revised

4 Name of Student: STUDENT REGISTRATION FORM (continued) New Federal legislation, the No Child Left Behind Act, requires that all school divisions report student information regarding the areas listed below. Please read each statement, or have the registrar read the statements for you, and answer each question as requested. Your child is considered to be Neglected/Delinquent if one of the following is true: In order to be eligible to be counted as neglected/delinquent, a child age 5 through 17 must live in an institution for neglected children and youth, which means a public or private residential facility, other than a foster home, that is operated primarily for the care of children and youth who (a) have been committed to the institution or voluntarily placed in the institution under applicable State law due to abandonment, neglect, or death of their parents or guardians; and (b) have had an average length of stay in the institution of at least 30 days; OR Must live in an institution for delinquent children and youth, which means a public or private residential facility that is operated for the care of children and youth who (a) have been adjudicated to be delinquent or in need of supervision and (b) have had an average length of stay in the institution of at least 30 days. Is your child Neglected/Delinquent? Yes No Your child is considered to be Homeless if one of the following is true: 1) Shares the housing of others due to loss of housing, economic hardship or similar reason; 2) Lives in motels, hotels, trailer parks or camping grounds due to lack of alternative adequate accommodations; 3) Lives in emergency or transitional shelters; 4) Abandoned in hospitals; 5) Awaits foster care placement; 6) Has a primary residence that is a public place or a place not designed for or ordinarily used as regular accommodation; 7) Lives in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations or similar settings. Is your child Homeless? Yes No If yes, which item above applies to your situation? Your child is considered to be a Migratory Child if one of the following is true: The term migratory child means a child who is, or whose parent or spouse is, a migratory agricultural worker, including a migratory dairy worker, or a migratory fisher, and who, in the preceding 36 months, in order to obtain, or accompany such parent or spouse, in order to obtain temporary or season employment in agricultural or fishing work: (a) Has moved from one school district to another; (b) In a State that is comprised of a single school district, has moved from one administrative area to another within such district; or (c) Resides in a school district of more than 15,000 square miles, and migrates a distance of 20 miles or more to a temporary residence to engage in a fishing activity. Is your child a Migratory Child? Yes No

5 Name of Student: Your child is considered to be a refugee if the following is true: An individual who is outside his/her country and is unable or unwilling to return to that country because of a well-founded fear that she/he will be persecuted because of race, religion, nationality, political opinion, or membership in a particular social group. This does not include persons displaced by natural disasters or persons who, although displaced, have not crossed an international border or persons commonly known as economic migrants, whose primary reason for flight has been a desire for personal betterment rather than persecution. Is your child a Refugee? Yes No Your child is considered to be an Immigrant if ALL of the following are true: The term immigrant children and youth mean individuals who: (a) Are aged 3 through 21 (b) Were not born in any State; and (c) Have not been attending one or more schools in any one or more States for more than 3 full academic years. Is your child an Immigrant? Yes No I have willfully and knowingly provided you with the correct information. I will provide you any new information concerning my child as it occurs. Parent/Legal Guardian Signature Date No student can be prevented from participation in any program solely because of his/her race, color, national origin, gender, age, religion, or disability. A procedure for resolving complaints alleging discrimination on the basis of race, color, national origin, gender, age religion, or disability may be found in the manual for Policies and Regulations of the Gloucester County Public Schools. The Section 504 and Title IX Coordinator for the Gloucester County Public Schools is: Ms. Rita Cargill-Brown, Coordinator Section 504 and Title IX Gloucester County Public Schools 6489 Main Street Bldg. 2 Suite F (804) Last updated